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In 1993, CDC recommended that hospitals and associated clinics in areas with
high human immunodeficiency virus (HIV) prevalence offer HIV testing routinely to
all patients aged 15--54 years (1). Although voluntary routine screening
among hospitalized (2) and emergency department patients
(3) can identify many undiagnosed HIV-infected persons, few screening programs have been
implemented in these settings. A 1997 study at Grady Memorial Hospital, Atlanta, Georgia,
found that nearly two thirds of inpatients newly diagnosed with acquired
immunodeficiency
syndrome (AIDS) had received medical care within the Grady health system
during the 12 months preceding admission*
(4); these previous encounters were missed opportunities for earlier diagnosis of HIV. In response to the 1997 study,
investigators studied routinely recommending HIV testing to patients presenting to the
urgent-care clinic, an ambulatory clinic that provides episodic medical care to indigent and
low income adults. This report summarizes the results of that study in which,
compared with 1999 when testing was based on symptoms or risk behaviors, more patients
were tested for HIV, more HIV infections were detected, and more infected persons
learned their diagnosis and entered into care. These results reflect the benefits
of recommending HIV testing routinely to patients in medical facilities located in
areas with high HIV prevalence.

For 24 weeks (i.e., March 20--September 1, 2000), clinicians were encouraged
to recommend HIV testing to all urgent-care clinic patients aged 18--65 years who
were neither known to be HIV
seropositive nor tested during the preceding 6 months.
These 24 weeks were compared with testing during the same 24 weeks in 1999, when
HIV testing was conducted only when clinicians were concerned about patients'
symptoms or risk behaviors. During the study period, posters encouraging patients to be
tested for HIV were displayed prominently, and patients received a brochure about HIV
and HIV testing before discussions with their heath-care providers. Patients who
accepted testing provided written consent and were not charged for HIV testing, which
was conducted with either a rapid test (Single Use Diagnostic System [SUDS] HIV-1
Test [Abbott-Murex Corporation, Norcross, Georgia]) or a standard enzyme
immunoassay (EIA). All SUDS tests were supplemented with EIA; all positive SUDS and EIA
tests were confirmed with Western blot. Clinicians, counselors, or study
investigators trained in HIV counseling delivered test results; a physician's assistant telephoned
or wrote to HIV-seropositive persons who had left before their SUDS results
were available or who did not return to the clinic for their EIA result. The study
was approved by the human subjects research committees of CDC, Emory University,
and the Grady Research Oversight Committee.

Patients were defined as knowing their test result if discussion of results
was documented in the medical record or clinic HIV testing log or if patients had a CD4
test within 2 months after their positive HIV test. Entry into care was defined by a record
of a visit to the Grady infectious disease clinic within 4 months following the positive
HIV test.

Approximately 20,000 clinic visits occurred during each of the two periods
(i.e., 1999 and 2000) (Table 1). Comparing 2000 with 1999, 1687 more patients were
tested, 27 more infections were newly detected, 27 more patients were informed of their
HIV-positive test result, and twice as many HIV-seropositive patients (26 versus
13) entered into care§ (Table 1). During the study, infected persons may have had
HIV detected at an earlier stage of infection; 28 (67%) of 42 persons had a CD4+ T
cell count >200 cells/µL during the study period compared with 10 (45%) of 22 during
1999 (p=0.1). Additional information on HIV test eligibility, provider recommendations,
and testing patterns was collected from 8 a.m. to 5 p.m. weekdays during the study
period¶. Among the 13,039 patient visits to the urgent-care clinic during these hours,
10,719 were eligible to be offered HIV testing. Among those eligible, 6421 (60%) were
offered testing and 2564 (40%) accepted. Among those who accepted testing, 1839
(72%) were actually tested. Among 886 patients tested with SUDS, 236 (27%)
received results the same day.

Editorial Note:

HIV testing usually relies on a patient's request or a
health-care provider's concern about symptoms or risk behaviors. This report indicates that
when providers at an urgent-care clinic in a high prevalence area routinely
recommended HIV testing, more persons were tested, more HIV infections were detected, and
more patients with newly detected infections learned their diagnosis and entered into
care. Patients often were diagnosed earlier in the course of their infection.

Despite the benefits of routinely recommended testing, barriers to this approach
exist, as demonstrated by the proportion of patients who were not offered testing,
did not accept testing, and were not tested once they had accepted. In addition, 26%
of patients with newly detected infections did not learn their HIV-positive diagnosis,
and 53% of those who learned their diagnosis did not enter into medical care.

The findings in this report are subject to at least four limitations. First, some
newly diagnosed patients may have sought care from providers outside the Grady
health system (e.g., private providers or other public health facilities) and would not
have been recorded as having received care. Second, the large proportion of patients
tested during both periods for whom CD4 count data were unavailable limited
the comparison of the stage of infection among patients diagnosed in 1999 with
those diagnosed in 2000. Third, the proportions of patients who were eligible for,
offered, accepted, and were actually tested from 8 a.m. to 5 p.m. weekdays may have
differed from the 1999 comparison period or other study hours. Finally, no data were
available to evaluate whether characteristics of the clinic population changed
between comparison periods.

The findings in this study suggest some strategies clinics can use to increase
the acceptance, feasibility, and effectiveness of routinely recommended testing.
To increase the numbers of patients providers recommend for testing, providers must
be convinced that time demands will not be excessive; to increase the number of
patients who accept testing, patients must believe that HIV testing and the subsequent
results are relevant. HIV risk can be assessed quickly using screening questions, and
patients can be referred for client-centered prevention counseling when necessary
(5). In this study, posters and brochures provided basic HIV test information and helped
providers focus on issues specific to the individual patient. Rapid tests that could be performed
in the clinic rather than a hospital laboratory and that could use either oral fluids or
whole blood obtained by fingerstick** might increase the acceptability of HIV testing and
the number of patients that receive test results in a clinic. In addition, medical centers
must develop clear, concise strategies that would facilitate medical care and
prevention counseling for newly diagnosed patients. Convenient and efficient links to HIV
medical care are benefits to having HIV testing in a clinic; however, informing patients of
their diagnosis is insufficient to ensure that they will receive HIV-specific medical care.

Testing for HIV infection in high HIV prevalence areas has become more
important and more feasible since 1993. Medical therapy now can reduce substantially
HIV-related morbidity and mortality, prevention counseling can help HIV-infected
persons protect their partners by adopting safer behaviors, and earlier HIV diagnosis
increases the benefits of both treatment and prevention
(6). Approximately 300,000 HIV-infected persons in the United States may not know that they are infected
(7), and missed
opportunities for earlier diagnosis of HIV frequently occur in medical settings
(4).

Recommending HIV testing routinely in clinical settings presents an opportunity
to target high prevalence communities, destigmatize HIV testing, and better link
HIV-infected persons to care and prevention services. Counseling and testing
are potentially cost saving because they can reduce transmission
(8); however, institutions are unlikely to absorb these costs. Public health departments and other HIV
prevention programs can assist with financial and/or human resources in implementing
routinely recommended HIV testing at clinics in high HIV prevalence areas. Health
departments and administrators of clinical facilities in such areas are encouraged to adopt a
policy of routinely recommending HIV testing.

Alexander L, Sattah M, Ziemer DB, Del Rio C. Missed opportunities for HIV diagnosis at
an inner city hospital in the United States [Abstract 43131]. Presented at the XII
International Conference on AIDS, Geneva, Switzerland, June 28--July 3, 1998.

*Median of four visits per patient; the most frequented departments were the
emergency department and the urgent-care clinic.

 Based on patient interview and medical record review.

§ This intervention was neither designed nor expected to improve the proportion
of infected persons who entered into care; the proportion was approximately the same
for the two periods (i.e., 13 [46%] of 28 in 1999 and 26 [47%] of 55 in 2000).

¶ Urgent-care clinic hours during 1999 and 2000 were Monday--Friday from 8 a.m. to 10
p.m. and weekends from 9 a.m. to 7 p.m.

** Such tests would eliminate the need to wait for a phlebotomist, have blood drawn,
and return for a second visit to receive test results. SUDS, the only rapid HIV test licensed
in the United States, is labor intensive, and most patients tested with SUDS in this
study did not receive their SUDS result on the same day that it was performed.

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